spring 2014 Flashcards
0
Q
what is answered by the pre-op assessment
A
- is the pt in optimal health
- can, or should, the pts physical or mental condition be improved before surgery
- risk assessment: does pt have any health problems or use any meds that could unexpectedly influence peri-operative events?
1
Q
Goal for Preop assessment
A
- Optimize care, satisfaction, and comfort
- minimize morbidity and mortality
- minimize surgical delays or cancellations
- determine appropriate post-op disposition
- evaluate health status and determine if any further consultative, diagnostic investigations are needed
- formulate most appropriate anesthetic plan
- Optimize communication among members of the surgical and anesthetic teams
evaluation should be efficient and cost-effective
2
Q
how do anesthesia providers get the most useful data
A
pt medical history- includes medical record and pt interview
3
Q
what are we looking for with pre-op assessment
A
- previous surgical history and family anesthetic history
- medication history
- difficult airway
- disease state of pt (severity, impact on activities, current and recent exacerbations, stability, treatments and interventions)
4
Q
preop eval includes
A
- pt history
- physical exam
- labs
- medical consults
- ASA class
- formulate plan
- discuss plan
- informed consent
- documentation
5
Q
pt history: sources
A
- pt/parent/family
- or schedule
- pt chart
- surgeon/specialist consutants/physicians
6
Q
confirm schedule with or team and assertain
A
- time;length of procedure
- anatomical location
- position
- xray needed?
- procedure (s)
- Or table position
7
Q
the OR schedule will tell you
A
Demographics- name , age, sex
- procedure
- surgeon (s)
- type of anesthesia
8
Q
chart review
A
- demographics
- diagnosis/procedure
- consent
- prior h&P
- labs
- EKG, PFTs, xray
- vital signs
- medication allergies
9
Q
Inpts specifically check ? in chart
A
- progress notes
- medication sheets
- nursing notes
- old anesthetic records
- complications?
10
Q
preop interview- 6 purposes
A
- obtain pertinent medical history
- formulate anesthetic plan
- obtain informed consent
- pt edu
- improve efficiency, reduce cost of periop care
- utilize operative experience to motivate pt to more optimal health status
11
Q
take a good history
A
- confirm findings from chart review
- open-ended questions
- general to specific
- organized and systematic
- layperson terminology
- individulized
- control environment
12
Q
NPO
A
2 hrs for clear liquids for all pts
4hr breast milk
6 hr formula or solids; light meal
8 hrs heavy meal- fried/fatty- GUM/CANDY
13
Q
history (steps on how to take and what to include)
A
- introduce self
- confirmation of pt
- co-existing diseases
- meds- allergies
- previous anesthetic (surgeries
- exercise tolerance
- sleep apenal hx
- etoh abuse?
- drug abuse/ tobacco use?
- lmp?
14
Q
who is an aspiration risk?
A
- Age extremes 70
- Ascities
- collagen vascular disease, metabolic dx (DM/obese/ESRD/hypoth
- Hiatal hernia/GERD/ Esophageal surgery
- mechanical obstruction (pyloric stenosis)
- prematurity
- preggers
- neurologic dx
15
Q
the physical
A
general impression airway heart lungs cns/pns surgical site
16
Q
what you need to get from the surgeon
A
- procedure
- position
- special considerations
- confirm abnormal findings
- labs
- blood ordered
- abx?
17
Q
general impression
A
height/weight-
physical features
neuro status
vs
18
Q
neuro specific
A
- ** depends on baseline***
- motor- gait, grip strength, ability to hold arms forward ect
- sensory
- muscle reflexes
- CN abnormalities
- mental status
- speech
19
Q
obesity def and formula
A
30% over ideal body weight
m- IBW= 105+6lb for each inch over 5 feet
w- IBW= 100+5lb for each inch over 5 feet
20
Q
airway exam
A
- mallampati class
- thyromental distance
- head and neck movement
- neck circumference
- interincisor distance
- dentation
- relevant craniofacial deformities
22
Q
heart/cv
A
auscultate- RRMBE(extremity pulses)- rate rhyth,murmur, bruit and ext
bruits, extremity pulses and edema
23
Q
lungs
A
inspection
auscultation
percussion
palpation
cyanosis, clubbing, accessory muscles- work of breathing
24
Q
other parts of the physical exam
A
surgical site
- iv
- position
- monitoring
25
sensitivity r/t labs
be positive in the patient with a disease
25
types of surgery
minimal
moderately invasive
highly invasive
26
specificity r/t labs
to be negative in the pat without disease
27
asa status
to classify the physical condition of the pt requiring anesthesia and surgery
* independent of the procedure and surgical risk
- subjective communication tool
28
ASA1
normal healthy pt; no systemic disease
29
ASA 2
mild to moderate systemic disease, well controlled, no functional limitation
30
ASA3
sever systemic disease, functional limitation
31
ASA4
severe systemic disease that is a constant threat to life
32
ASA 5
moribund pt, not expected to survive with or without the surgical procedure
33
ASA6
pt declared brain dead whose organs are being harvested for donation
34
E
emergency operation required
35
Parts to Formulate Anesthetic plan
```
type of anesthesia
drugs
monitors
airway
positioning
intraop monitoring
```
36
pt prep/edu
- discuss choices of anesthetic technique(consent)
- explain iv
- descrive use of local anesthetics, meds. fluids
- discuss airway management
- explain monitors
- process to the or
- pacu care
- possible outcomes- sore throat ect
37
what to document
```
H&P
INformed consent
NPO status
Allergies
ASA
Pre-op VS
- Labs/tests/ consults
```
38
why do we do an airway eval for every pt
- to PREDICT ease or difficulty of airway management
39
what do we take into consideration for preop airway
- type of surgery
- type of anesthetic
- safety factors (positioning)
40
review airway structures
nose--- fx, septal deviation, bleeding bc very vascular, sinuses* caution
pharynx---- teeth, tounge, hard, soft palate- shape of these,
larynx-
trachea- deviated? visualize it?
41
why intubate
- airway protection (aspiration, secretions (blood, saliva, foreign objects= laryngospasm, edema
- maintain patent airway
- provide positive pressure ventilation
- maintain adequate oxygenation
- deliver predicable FiO2
- Provided positive end-expiratory pressure
42
indications for a mask case
- no instrumentation of the airway required
- difficult airway not present
- surgeon does not need access to the head/neck
- no airway bleeding/secretions
- short duration
- no table position changes
- have to be able to get a good seal and be able to overcome obstruction with airway/chin lift
43
airway assesment history
- had general anesthetic before? y/n difficult?
- were you awake for an intubation
- severe sore throat/dental injury?
- co-existing diseases?
- surgical history that could effect airway?
44
co-morbidities
- lesions of larynex
- thyroid disease
- cancer
- cerd
- diabetes
- sleep apnea- obesity
- genetic disorders
- RA
- musculoskeletal
- scleroderma
46
sugeries that will effect airway
- tracheostomy/scar
- nex dissection
- UVPP (uvulo palytopharengeal plasty )
- Cervical neck instrumentation
47
physical exam (2 part)
- general appearance (head, neck- size circum and length, presence of heavy facial hair)
Mouth (lips, gums, tissues)
- Teeth (length of incisors, condition of teeth (missing protrusion, overbite), relationship of upper incisors to lower incisors, dentures/bridges out)
47
normal mouth opening
4cm or > 2 FB
48
what's the neck size cut off for too large?
16in or 40 cm-- women
17in man
>60cm
49
physcial exam
look at the size and mobility of tongue
- size and shape of mandible ' maxilary overgrowth
- assess for TMJ
50
Thyromental distance definition
distance from mandible to prominence of thyroid cartilage (tyro-mental)
51
thyromental distance #
6.5cm (50mm) or 3 FB
53
Normal Hyoidmental distance #
2 FB
54
assess preop
cervical ROM
55
what joint is key for head movement
atlanto-occipital joint
56
must also include in an good airway assessment
breath sounds
57
Mandibular protrusion test graded by
```
CLASS A:
class b and c
```
58
Class A for mandibular protrusion Test (MPT)
lower incisiors can be protruded anterior to the upper incisiors
59
CLASS B (MPT)
the lower incisors can be brought edge to edge with upper incisors
60
CLASS C (MPT)
lower incisors cannot be brought edge to edge with upper incisors
61
dental assessment
- poor dentition
- loose teeth
- chipped teeth
- capped
- removable brideges
- dentures
62
Top right back tooth is #
1
63
Top right front tooth is #
8
64
Top left tooth is #
9
65
back left tooth is #
16
66
bottom left tooth is #
17
67
bottom right tooth is #
32
68
mallampati definition
is a prediction of what you will see at the cord level based on the size of the tongue
69
how do a mallampati exam
- pt sitting head neutral
| - open mouth as wide as possible and stick out tongue
70
class one see
entire uvula, pillars, fauces, soft and hard palate
71
class 2
see tongue is covering the tip of the uvula
72
class 3
see the hard and soft palate
73
class 4
hard palate only
74
strong predictor of difficult airway
- obesity
- decreased head and neck movement
- decreased jaw movement
- receding mandible
- "buck teeth"
- mallimpati
- short neck
75
when do most difficult airway issues happen
66% induction
1-7% of people will be difficult intuabtions- in general!
76
if you can bag your pt what pathway are you in
nonemergent pathway
77
can you use a fiberoptic after a couple of attempts
no you'll have blood or secretions in the airway and wont beable to see
78
awake intubation end pts
succeed, fail (cancel case, consider other option, surgical airway)
79
what do you need for an airway set up
- laryngoscope
- blades 2 types
- oral/nasal airways several sizes
- tongue depressor
- ET tube 2 sizes
- Stylet
- Syringe
- Suction
- ambu-bag
- Lma
80
difficult airway cart
- et tubes
- et guides
- laryngoscop blades
- supraglottic airway -- combitube
- retrograde intubation eq
- fiveroptic intubation equip
- surgical airway stuff
- exhaled co2 detector
81
what do you document?
preop-- dental, c-ROM, Mallampati class, TM distance, mouth opening
- Post intubation----- visualization, trauma, equipment used, hemodynamic or respiratory changes
- post-extubation--- loose teeth intact, airway patency, adjuncts airway maneuvers used
82
why do we care about positioning
- pt safety
- comfort
- surgical exposure and/or surgical access
- *can cause undesirable physiological changes and injuries
83
describe the OR table
Length 80.7 in
wt limit 136kg (270lb)
newer wt lim 270kg (600lbs)
84
where is the center of gravity for the OR table
over the post
85
how do you transfer a pt to the OR table
- stretcher along side OR table ___ LOCK BOTH
- OR table has a draw sheet
- staff members on stretcher side and bed side
- pt trsfers self or moved by staff (watch extrem and h/neck aligned with spine
- then apply safety strap
86
most common operative positions
- supine/dorsal decubitus position (trendelenburg/rT)#1
- Lithotomy
- prone or ventral decubitus position
- lateral decubitus
- sitting
87
Supine
access to airway and arms (iv/monitors)
| less physiologic changes
88
supine pillow placement under head y?
- proper sniffing position
- avoids dorsal extension and lateral flection of neck (brachial plex inj)
- doughnut - avoids alopecia
- no eye pressure
89
what do we do with the draw sheet under the pt?
tuck it under the pt - not the mattress
90
Supine arm conciderations
- - properly secured to or table with sheet/arm board
- abd <90 degrees, avoids stretch brachial plexus
- padded
- safety straps
- hands supinated!!!!! or palms to the side of the leg
91
Supine lower ext consideration
heels not hanging over bed and PADDED
- *pillow under knees/slight flextion of hips and knees
- no crossed feet/legs
- devices on to increase venous return and decrease risk DVT
- safety strap
92
how do nerves get injured
- stretching
- compression
- kinking
- ischemia
- transection
93
risk factors for nerve injury
- position
- prolonged surgery
- technique (GA)
- Preexisting diseases (obese, Diabeties)
94
Stretching is the most common cause of _________ injury and give examples
Brachieal plex
- arm +- board falls off table,
- neck extention/ turned to side
- arm board extended/abd greater 90
- cardiac retractors
95
how does the pt feel with a brachial plex inj
- electric shocks/burn
- numb or weak arm
- no or weak motor control of shoulder/elbow
- pain
96
how to inj the radial nerve
compression lateral aspect of the humerus against- surgical retractors, ether screen, mismatched arm board, repeat bp inflation
====WRIST DROP, weakness in ABD of thumb and numbness 1,2, and ring fingers
97
ulnar nerve damage
THE MOST COMMON POST OP PN INJ (more common in men and very muscular ppl)
- compression of nerve in cubital tunnel--- btw olecranon and medial epicondyle of humerus
- stretch inj too.
98
ulnar nerve inj looks like
CLAW HAND
- cant ABD or oppose 5th finger
- weak grip ulnar side of fist
- loss sensation PALMAR 4/5 fingers
- atrophy of intrinsic muscle of hand
99
how to decrease ulnar nerve injury
- pad arm boards
- avoid downward compression by strap
- assure surgical personnel do not compress pts arm
- place bp cuff proximally so that it does not impose on ulnar groove or cubital tunnel
- avoid prolonged FLEXION of elbow
100
Supine CV changes
minimal
initally- increased venous return to heart (increase preload, SV, CO)
which activates baroreceptors which decrease sympathetic outflow and increase parasympathetic impulses= COMPENSATORY DECREASES IN HR AND PVR
reduced venous drainage from lower extremities
101
what is a possible complication of supine position and obese folks, preggers, ascites
ivc compression syndrome
so do left lateral position if better tolerated
102
Vent changes supine
FRC decreases +/- 800ml (r/t cephalad displacement of the diaphram and compression of lung bases)
muscle relaxants further reduce lung volumes
- loss of chest wall muscle tone---- reduce oppos
103
Hyoidmental distance definition
Distance from hyoid to mandible
104
normal hyoidmental distance
2 FB
105
what joint should be concerned about with head ROM
atlanto-oxcipital joint
106
last part of airway assessment
LISTEN TO B. BREATH SOUNDS
107
mandibular protrusion test ranked how
class A/B/c
108
Class A is---
normal- the person's lower incisors can protrude anterior to upper incisors
109
Class B-
lower incisors meet the upper incisors
110
class c-
the lower incisors cannot be brought to the edge of the upper incisors
111
dental assessment includes
```
dentition
lose teeth
chipped teeth
caps
removable bridges
dentures
```
112
mallimpati
prediction of what will see at the cords related to the size of the tongue
do not as ah
head in neutral position
113
what axis line up in sniffing position
the oral, pharyngeal and laryngeal
114
what are some strong predictors of diff airway
```
obesity
decreased head and neck move
decreased jaw mvt
receding mandible
"buck teeth"
```
115
what is the % difficult intubation
1-7%
116
when do most of the diff intubations occur
induction
117
when is it not an option to use a fiberoptic scope
after a couple of attempts because there is going to be blood and secretions now in the airway
118
when do you move to the emergency pathway
when you can't bag the pt
119
first thing u do when you realize that you are in the emergency pathway
call for help
120
nonemergency pathway def
mask ventilation is adequate
121
initial intubation fails- what are the options
awake patient, call for help, or return to spontaneous ventilation
122
for a difficult airway 2 options to proceed
awake or reg intubation
123
with success confirm ett placement
- etco2
- b chest rise
- breath sounds
- color change
124
airway set up
- laryngealscope
- 2 blades
- 2 ett sizes (with stylets and syringes)
- lma
- tongue depressor
- suction
- ambu bag
- oral/nasal airways
-
125
don't for get about diff airway cart
fiberoptic stuff, jet vent, retrograde equip, co2 detector, surgical airway
126
document preintubation
dental exam, cROM, mallimpati class, Tm distance, mouth opening
127
document post intubation
vizulaized, trauma, equipment used, hemodynamic or resp changes
128
doc post extubation
loose teeth intact, airway patency, adjunct airways used
129
final pre op checklist for patient prep
```
iv/fluids
premeditated
anesthetic plan
lab/ekg
blood products?
need for inhaler/steroid/abx?
```
